Rectovaginal Fistula Research Articles

Postoperative rectovaginal fistula: stoma may not be necessary—a French retrospective cohort

BackgroundPostoperative rectovaginal fistula leads to a loss of patients’ quality of life and presents significant challenges to the surgeon. The literature focusing specifically on postoperative rectovaginal fistulas is limited. The objective of the present study is to identify factors that can enhance the success of the management of this postoperative rectovaginal fistula.MethodsThis retrospective multicentric study included all patients undergoing surgery for rectovaginal fistulas, excluding those for whom the etiology of rectovaginal fistula was not postoperative. The major outcome measure was the success of the procedure.ResultsA total of 82 patients with postsurgical fistulas were identified, of whom 70 were successfully treated, giving a success rate of 85.4%. On average, these patients required 3.04 ± 2.72 interventions. The creation of a diversion stoma did not increase the success rate of management [odds ratio (OR) = 0.488; 95% confidence interval (CI) 0.107–2.220]. Among the 217 procedures performed, 69 were successful, accounting for a 31.8% success rate. The number of interventions and the creation of a diversion stoma did not correlate with the success of management. However, direct coloanal anastomosis was significantly associated with success (OR = 35.06; 95% CI 1.271–997.603; p = 0.036) as compared with endorectal advancement flap (ERAF). Other procedures such as Martius flap did not show a significantly higher success rate.ConclusionThe creation of a diversion stoma is not necessary in closing a fistula. ERAF should be considered as a first-line treatment prior to proposing more invasive approach such as direct coloanal anastomosis.

S3172 A Rectovaginal Fistula Associated With Squamous Cell Carcinoma of the Rectum

S3172 A Rectovaginal Fistula Associated With Squamous Cell Carcinoma of the Rectum

Evagination method for rectovaginal fistulas

AIM: to assess early and late results of the evagination method for the treatment of rectovaginal fistulas (RVF) in patients with anal incontinence due to muscle defect in the anterior semicircle. PATIENTS AND METHODS: the study included 45 patients. The prevailing etiology of RVF was delivery lesion in 19/45(42.2 %). The median follow-up was 6 (4; 8.5) months. On day 30 after surgery, the outcome was assessed clinically. Late outcomes were assessed in all patients 3–12 months including clinical control, transanal ultrasound and sphincterometry. RESULTS: recurrence occurred in 9/45 (20 %) patients. The significant improvement of continence was revealed: in mean pressure in rest (p = 0.004), in maximum contraction pressure (p < 0.0001), in Wexner incontinence score (p < 0.0001). With a fistula opening less than 16 mm, the recurrence risk increases (p = 0.0003). CONCLUSIONS: the evagination method is effective option in extent septal defects and correcting additional analsphincter insufficiency.

Rectovaginal fistulas : Differentiated diagnostics and treatment

Rectovaginal fistulas (RVF) represent less than 5% of anorectal fistulas. The classification of RVF is based on the localization (low vs. high) and the etiology. The most frequent causes of RVF are birth trauma, Crohn's disease, previous surgery and pelvic irradiation. In most cases a clinical diagnostic assessment is sufficient. Additionally, endosonography is areliable tool to detect sphincter defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are reserved for special situations (e.g., RVF related to anastomotic leakage, after pelvic irradiation or associated with complex perianal fistulizing Crohn's disease). The surgical treatment is primarily oriented to the localization and etiology. Surgical techniques range from local procedures (e.g., endorectal advancement flap repair, transvaginal or transperineal closure) up to more invasive tissue interposition (e.g., bulbocavernosus muscle fat tissue flap or transposition of the gracilis muscle). In "high" RVF transabdominal approaches such as coloanal anastomosis, pull through procedures or omental interposition are indicated. All surgical procedures show high recurrence rates. Several operations are mostly necessary and a stoma creation is often required.

Primary mucinous adenocarcinoma intestinal type of the vulva arising at site of prior vulvar Crohn’s disease: A case report and review of the literature

Introduction: Vulvar mucinous adenocarcinoma is a rare subtype that likely arises from atopic gastrointestinal tissue. The evaluation and treatment of this condition often requires a multidisciplinary approach. Case Report: Our patient is a 55-year-old female with a history of Crohn’s disease who initially presented with a painless vulvar mass associated with occasional bleeding. Notably, the mass presented at the site of a prior rectovaginal fistula. A vulvar biopsy was performed with pathology consistent with intestinal type mucinous adenocarcinoma. Further workup was notable for imaging showing retroperitoneal and pelvic metastatic lymphadenopathy, hypermetabolic liver and bony metastases, and pulmonary nodules concerning for metastases. Following discussion at tumor board, the patient was recommended treatment with 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX), and bevacizumab. Unfortunately, prior to starting chemotherapy, the patient presented to the emergency department with dizziness and weakness and was found to have brain metastases. She ultimately elected to be discharged home on hospice care. Conclusion: Vulvar mucinous adenocarcinoma is a rare subtype tumor with limited literature on treatment options. For these rare cases, clinicians can consider treatment modalities for colon carcinomas rather than vulvar carcinomas.

Anorectal Malformation Patients in Australia and Europe: Different Location, Same Problem? A Retrospective Comparative Registry-based Study

Anorectal malformations (ARM) encompass a spectrum of rare congenital defects of the rectum and anus, requiring specialized reconstructive surgery. To improve epidemiological and clinical research in rare diseases such as ARM, collaborative efforts and patient registries are key.This retrospective study pools clinical data over a 30-year period from two ARM patient registries (The Royal Children's Hospital (RCH) in Melbourne, Australia, and the ARM-Network Consortium in Europe). It aims to draw comparisons on demographics, management, and outcomes between ARM patients in Australia and Europe.A total of 2947 ARM patients were included in the analyses. The RCH cohort had more complex ARM types (including rectal atresia and recto-vaginal fistula) and more associated anomalies, specifically skeletal, cardiac, and/or trachea-esophageal, than ARM-Net patients. Other patient characteristics were similar. Treatments clearly differed between the groups. European surgeons favoured the PSARP approach for both less complex and more complex ARM types, where Australian surgeons opted more often for cutback surgery in less complex, and laparoscopic assistance in more complex types. Complications were differently distributed, with less complications after LAARP and more after PSARP at RCH, compared to ARM-Net. While RCH patients more often required a redo, ARM-Net patients more commonly underwent anal dilatations.Anorectal malformation patients in Australia and Europe had minor differences in disease characteristics, and both operative and medical approaches differed. Joint efforts such as the present study emphasize the importance of collaboration to elucidate areas of improvement where surgeons may learn from each other across the world, ultimately improving patient outcomes. Type of StudyOriginal Research. Level of EvidenceIII.

Use of Vaginoscopy after Vaginoplasty in Individuals with Congenital Adrenal Hyperplasia

Study ObjectiveTo explore the use of exam under anesthesia with vaginoscopy (EUA-V) following vaginoplasty in patients with congenital adrenal hyperplasia (CAH). DesignRetrospective cohort MethodsAn IRB-approved retrospective chart review was performed of the post-surgical follow-up care of all patients diagnosed with classical CAH who sought care at a tertiary children's hospital from 2000-2017 and had undergone vaginoplasty at that institution. ResultsTwenty-six patients met inclusion criteria. The median age at vaginoplasty was 1.25 years (IQR: 0.67, 9). Median post-surgical follow-up was 5.5 years (IQR: 1.5, 9). Twenty six EUA-Vs were performed, on 22 patients. Four were for complication assessment (rectovaginal fistula (1); urethrovaginal fistula (3)—on the same patient). The remaining 22 EUA-Vs, performed on 20 patients with two each undergoing two EUA-Vs, were planned for routine evaluation of vaginal patency. They were done a median of 0.67 years (IQR: 0.25, 2) following surgery and at a median of 6.67 years of age (IQR: 1.75, 12). Of these, five EUA-Vs identified stenosis in five patients (25%), a median of 0.91 years (IQR: 0.5, 7) after surgery, at a median age of 8.42 years (IQR: 2, 10.92). Of the four who did not undergo EUA-V, one had stenosis on clinical exam with ultrasound-verified hematocolpos. The remaining three were all prepubertal at last follow-up. ConclusionThe majority of CAH patients following vaginoplasty underwent routine EUA-V, roughly a quarter of which detected stenosis. EUA-Vs may play a beneficial role in routine post-op care following vaginoplasty in patients with CAH.

Abdominal Hartmann reversal versus combined transanal/abdominal approach: Outcomes and technical notes

Background: Hartmann’s reversal (HR) is one of the most technically challenging operations in colorectal surgery. A small percentage of HR operations are performed laparoscopically. The pelvic dissection is the key point of the procedure and can be demanding when the rectal stump is extraperitoneal and if the pelvic condition is complex. Methods: A retrospective observational single-center study was designed to analyze the outcomes of patients with an extraperitoneal rectal stump who underwent HR from January 2015 to December 2020 at IRCCS Sacro Cuore Don Calabria Hospital in Negrar of Valpolicella. The patients were divided into two groups: group 1 underwent a purely abdominal Hartmann’s reversal (A-HR) and group 2 underwent a combined transanal and abdominal Hartmann’s reversal (TA-HR). Results: Forty-two patients were divided into the groups as follows: 22 (52.3%) patients in the A-HR group versus 20 (47.62%) patients in the TA-HR. The transanal approach did not significantly affect the operative time. The rate of rectovaginal fistula was higher in the TA-HR group (65% vs. 4.5%). The anastomosis was performed mechanically in all A-HR cases and 50% of TA-HR patients (P < 0.01). No difference in temporary stoma creation was found. The rate of complications was lower in the TA-HR group (P = 0.05). The A-HR group was statistically significantly associated with redo surgery (P = 0.04). Stoma failure rate at the end of the follow-up did not differ between the two groups. Conclusions: Transanal Hartmann reversal seems to be a safe approach in patients with a complex pelvis and extraperitoneal rectal stump.

Protective defunctioning stoma in bowel segmental resection at the time of total hysterectomy for endometriosis: when less is more

PurposeTo compare postoperative complications in women undergoing total hysterectomy with segmental resection (TH-SR) for intestinal endometriosis with or without protective defunctioning stoma (PDS) confection.MethodsRetrospective cohort study conducted at the Gynecologic department of University Hospital of Lille (France) from January 2008 to January 2022 in patients undergone TH-SR for bowel endometriosis.Results100 women were considered for the analysis. PDS were performed in 56 women. The rate of rectal resections was significantly higher in the PDS group (p = 0.03). The mean operative time, AAGL scores and length of hospital stay were significantly higher in the PDS group (p = 0.002). The rate of grade III complication according to Clavien-Dindo classification was higher in the PDS group (p = 0.03). Among digestive complications, one case of anastomosis leakage (1.8%) and one case of recto-vaginal fistula (2.3%) was recorded in the non-PDS group, 4 cases of anastomosis stenosis were recorded in the PDS group (7.1%). Persisting bladder atony requiring self-catheterization over one month was the most common disturb (4.6% in the non-PDS group and 7.1% in the PDS group, p = 0.58). The distance of digestive lesion from anal margin was the only risk factor for digestive complications, persistent bladder atony, Clavien-Dindo IIIA and IIIB complications at the multivariate analysis (p = 0.04 and p = 0.06 respectively).ConclusionNo statistically significant differences were found in the rate of digestive complications in case of total hysterectomy and concomitant segmental resection when performing or not preventing stoma.

HIV-associated rectovaginal fistulae in children: a single-centre retrospective study in the antiretroviral era

PurposeAcquired rectovaginal fistulae (RVF) are a complication of paediatric HIV infection. We report our experience with the surgical management of this condition.MethodsWe retrospectively reviewed the records of paediatric patients with HIV-associated RVF managed at Chris Hani Baragwanath Academic Hospital (2011–2023). Information about HIV management, surgical history, and long-term outcomes was collected.ResultsTen patients with HIV-associated RVF were identified. Median age of presentation was 2 years (IQR: 1–3 years). Nine patients (9/10) underwent diverting colostomy, while one demised before the stoma was fashioned. Fistula repair was performed a median of 17 months (IQR: 7.5–55 months) after colostomy. An ischiorectal fat pad was interposed in 5/9 patients. Four (4/9) patients had fistula recurrence, 2/9 patients developed anal stenosis, and 3/9 perineal sepsis. Stoma reversal was performed a median of 16 months (IQR: 3–25 months) after repair. Seven patients (7/9) have good outcomes without soiling, while 2/9 have long-term stomas. Failure to maintain viral suppression after repair was significantly associated with fistula recurrence and complications (φ = 0.8, p < 0.05).ConclusionWhile HIV-associated RVFs remain a challenging condition, successful surgical treatment is possible. Viral suppression is a necessary condition for good outcomes.

Practical use of transanal decompression tube following the repair of fourth-degree perineal tears associated with vaginal delivery

BackgroundFourth-degree perineal tears associated with vaginal delivery (PTAVD) occur in approximately 0.25 to 6% of vaginal deliveries. A persistent challenge in treating fourth-degree PTAVD is the high incidence of anastomotic leakage, leading to impaired quality of life, marked by incontinence, rectovaginal fistula, and painful sexual intercourse. Thus, effective interventions are necessary. Herein, we report our successful approach in repairing a fourth-degree PTAVD, involving the placement of a transanal decompression tube (TDT) during the early postoperative period.Case presentationFive patients underwent the repair of fourth-degree PTAVD by suturing the mucosal and muscular layers of the rectum, and the vaginal wall in layers. Subsequently, a TDT was placed in the rectum, positioned 10–15 cm from the anal verge. The TDT was allowed to drain spontaneously without suction. Gastrografin enema examination was performed through a TDT, followed by a computed tomographic scan on postoperative days 3–4. After unfavorable complications were ruled out, the TDT was removed and the patients were transitioned to a normal diet.ResultAll patients showed favorable outcomes with no occurrence of vaginal fistula or incontinence.ConclusionThis simple intervention demonstrates potential efficacy in reducing anastomotic leakage following the repair of fourth-degree PTAVD.

Endoscopic management of long-standing rectovaginal fistula caused by foreign bodies.

Endoscopic management of long-standing rectovaginal fistula caused by foreign bodies.

Cloacal Repair for Rectovaginal Fistula With Sphincter Defect.

Cloacal Repair for Rectovaginal Fistula With Sphincter Defect.

Rectovaginal Fistula Due To Chronic Perineal Tear; A Case Report

An abnormal connection that exists between two epithelial surfaces or lumens of the rectum that reaches into the vagina is known as a recto-vaginal fistula (RVF). RVF is one unfortunate consequence of the underlying condition, such as trauma or surgery. According to the patient recap of the urogynecology clinic at M Djamil Hospital Padang (2023), from January to September, 6 patients had cases of rectovaginal fistula that needed to be repaired. Treatment of the underlying condition, the fistula, and its associated complications all fall under the umbrella of RVF management. Given that obstetrics, procedure is still the main cause in this case, the role of the field of urogynecology in the management of surgical interventions is important to maintain the quality of life of a woman. In this case report we present a case report of a 24-year-old woman with rectovaginal fistula and anal incontinence caused by chronic total perineal tear. The patient complained of feces discharge from the vagina since giving spontaneous birth to the first. Physical examination found defects in the internal sphincter (IAS) and external sphincter (EAS) at 11 until 14 o'clock. The patient then underwent sphincteroplasty and perineorrhaphy and showed improvement after surgical intervention

Transvaginal removal of rectal stromal tumor with Martius flap interposition: a feasible option for a large tumor at the anterior wall of the rectum.

Neoadjuvant imatinib treatment, followed by complete transvaginal removal, presents a feasible option for large rectal gastrointestinal tumors located on the anterior wall of the rectum and protruding into the vagina. The use of Martius flap interposition is convenient and can be employed to prevent rectovaginal fistula.

Evaluating the safety of high-intensity focused ultrasound treatment for rectal endometriosis: results from a French prospective multicentre study including 60 patients.

Is increasing the intensity of high-intensity focused ultrasound (HIFU) by 30% in the treatment of rectal endometriosis a safe procedure? This study demonstrates the safety of a 30% increase in the intensity of HIFU in the treatment of rectal endometriosis, with no Clavien-Dindo Grade III complications overall, and namely no rectovaginal fistulae. A feasibility study including 20 patients with rectal endometriosis demonstrated, with no severe complications, a significant improvement in digestive disorders, dysmenorrhoea, dyspareunia, and health status, although the volume of the endometriosis nodule did not appear to be reduced. A prospective multicentre cohort study was conducted between 2020 and 2022 with 60 patients with symptomatic rectal endometriosis. Following the failure of medical treatment, HIFU treatment was offered as an alternative to surgery. As the main objective of this study was to examine safety, all adverse events observed during the 6 months of follow-up were analysed and graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) and Clavien-Dindo classifications. Secondary objectives included evaluating the evolution of symptoms using validated questionnaires: gynaecological and digestive pain symptoms with a visual analogue scale, health status with the Medical Outcomes Study 36-item Short Form (SF-36) questionnaire, average post-operative daily pain level, and analgesic medication required in the 10 days following treatment. MRI was also performed at Day 1 to detect early complications. Finally, we performed a blinded MRI review of the evolution of the nodule at 6 months post-treatment. The procedure was performed under spinal anaesthesia for 30% of the patients. The median duration of treatment was 32 min. Fifty-five patients left the hospital on Day 1. MRI scans performed on Day 1 did not highlight any early-onset post-operative complication. Using the Clavien-Dindo classification, we listed 56.7% Grade I events, 3.4% Grade II events, and no events Grade III or higher. At 1, 3, and 6 months, all gynaecologic, digestive and general symptoms, as well as health status, had significantly improved. The evolution of the nodule was also significant (P < 0.001) with a 28% decrease in volume. The main objective was safety and not effectiveness. The study was not randomized and there was no control group. HIFU treatment for rectal endometriosis results in an improvement of symptoms with low morbidity; as such, for selected patients, it could be a valuable alternative to surgical approaches following the failure of medical treatment. The study was funded by the company EDAP TMS. Professors Dubernard and Rousset are consultants for EDAP TMS. Dubernard received travel support from EDAP-TMS. Dr F. Chavrier received industrial grants from EDAP-TMS. He has developed a device for generating focused ultrasonic waves with reduced treatment time. This device has been patented by EDAP-TMS. Dr Lafon received industrial grants from EDAP-TMS; he declares that EDAP-TMS provided funding directly to INSERM to support a young researcher chair in therapeutic ultrasound, which is unrelated to the current study. ClinicalTrials.gov identifier NCT04494568.

Management of vaginoplasty canal complications.

Increasing uptake of gender affirming surgery has allowed for a wider breadth of publication examining complications associated with vaginoplasty. This review aims to provide a comprehensive overview of complications associated with vaginoplasty procedures, focusing on intraoperative, early postoperative, and delayed postoperative complications across different surgical techniques. Intraoperative complications such as bleeding, injury of the rectum, urethra and prostate, and intra-abdominal injury are discussed, with insights into their incidence rates and management strategies. Early postoperative complications, including wound dehiscence, infection, and voiding dysfunction, are highlighted alongside their respective treatment approaches. Moreover, delayed postoperative complications such as neovaginal stenosis, vaginal depth reduction, vaginal prolapse, rectovaginal fistula, and urinary tract fistulas are assessed, with a focus on their etiology, incidence rates, and management options. Vaginoplasty complications range from minor wound issues to severe functional problems, necessitating a nuanced understanding of their management. Patient counseling, surgical approach, and postoperative care optimization emerge as crucial strategies in mitigating the impact of complications. Standardizing complication reporting and further research are emphasized to develop evidence-based strategies for complication prevention and management in vaginoplasty procedures.

Insights into Atresia Ani Type IV in Felis catus: Preliminary Epidemiolocal Findings Associated with Surgery.

Atresia Ani (AA) is a rare congenital anomaly in companion animals affecting rectal and anal development. Its incidence in cats remains unreported. This retrospective study aimed to characterize age, body condition, fistula size, and perioperative outcomes in Type IV Atresia Ani (with recto-vaginal fistula) in female cats. Surgical intervention is the primary treatment. Conducted over 2 years, the study included nine female cats diagnosed with Type IV Atresia Ani and recto-vaginal fistula undergoing surgery. Statistical analysis used the R program (version 4.2.1) with Rstudio®® extension. Significant results were observed at a 95% confidence interval and p < 0.05. The condition had an incidence of 4.7% among the 192 cats evaluated over a 2-year period. The findings suggest that a body condition score of 3, an age of 3 to 4 weeks, and a fistula length of 1 to 2 mm correlated with better surgical outcomes, reducing the likelihood of fecal incontinence and anal stenosis development, and enhancing defecation awareness during the perioperative period. This study is the first to report the disease incidence in cats undergoing surgery, according to the authors' knowledge.

Rectal Injury During Penile Inversion Vaginoplasty

ObjectiveTo evaluate the incidence, management and outcomes of rectal injury (RI) and subsequent rectovaginal fistula (RVF) during gender-affirming vaginoplasty (GAV) at a high-volume transgender surgery center. MethodsWe performed a retrospective review of pre-operative, intra-operative and post-operative findings of all patients with RI during GAV from January 2016-September 2022. Descriptive statistics were calculated using Microsoft Excel. ResultsRI occurred in nine of 1011 primary GAV and colorectal surgery (CRS) consulted in five cases, which included sigmoidoscopy with an air leak test in four and with temporary bowel diversion in two. Of the nine, six proceeded with full depth GAV, and three were converted to minimal depth vaginoplasty. Two had bulbospongiosus muscle interposition and none had a concomitant urethral injury. 1/9 with RI developed a RVF which occurred in a patient with prior perineal surgery and no intraoperative sigmoidoscopy. Three (50%) with full depth GAV developed vaginal stenosis postoperatively. ConclusionsRI during primary GAS in experienced hands is uncommon with an incidence of 0.89% in our series of 1011. Unusual tissue dissection planes were a risk factor. If injuries were identified intraoperatively, repaired with multilayer closure and evaluated by CRS, patients did well without the development of RVF despite completion of full depth GAV. It is reasonable to complete the full depth vagina, but patients should be advised of a significant risk of post-operative vaginal stenosis.

Comparative study on the establishment efficacy of four types of animal models of rectovaginal fistula in rabbits

Various surgical methods have so far been developed for treating rectovaginal fistula (RVF), each with its own advantages and disadvantages. The lack of standardized animal models of RVF is a major reason for the failure to establish a unified and effective surgical method for the treatment of RVF. This study aimed to explore the feasibility of an RVF animal model by magnetic compression and compare it with the traditional modeling method. Thirty-two female Japanese white rabbits were randomly divided into four groups: A, B, C, and D, based on how the rectovaginal septum was treated. The operation time, intraoperative blood loss, and model success rate of each group were determined. The experimental animals were euthanized 2 weeks after the operation. Their rectovaginal septum specimens were obtained. RVF was observed by the naked eye. The fistula size was measured. Histological changes of fistula were observed by hematoxylin and eosin and Masson staining. All rabbits completed the RVF model and survived 2 weeks after the operation. Groups A and B had no bleeding, while groups C and D had < 0.5 mL of bleeding. The magnet detached in 4–6 days in group A, while it remained in place for 2 weeks after surgery in group B. Only one group D rabbit had a plastic hose for 2 weeks after surgery. The RVFs of groups A and C healed by themselves. In group B, the fistula was well formed. In group D, fistula healing was observed in three animals and the diameter of the fistulas was only 2.82–4.64 mm in the other four animals. Groups B and D had a scar on the inner surface of fistulas. Our study shows that the magnetic compression technique based on the T-shaped magnet is a highly useful method to establishing a continuous and stable RVF model in rabbits.